Thyroid storm: an updated review.

Thyroid storm, an endocrine emergency first described in 1926, remains a diagnostic and therapeutic challenge. No laboratory abnormalities are specific to thyroid storm, and the available scoring system is based on the clinical criteria. The exact mechanisms underlying the development of thyroid storm from uncomplicated hyperthyroidism are not well understood. A heightened response to thyroid hormone is often incriminated along with increased or abrupt availability of free hormones. Patients exhibit exaggerated signs and symptoms of hyperthyroidism and varying degrees of organ decompensation. Treatment should be initiated promptly targeting all steps of thyroid hormone formation, release, and action. Patients who fail medical therapy should be treated with therapeutic plasma exchange or thyroidectomy. The mortality of thyroid storm is currently reported at 10%. Patients who have survived thyroid storm should receive definite therapy for their underlying hyperthyroidism to avoid any recurrence of this potentially fatal condition.

Piloting a National Curricular Resource for the Transition to Surgical Residency: Characteristics of Participating Schools and Their Students.

OBJECTIVE: To determine the extent to which U.S. Liaison Committee of Medical Education (LCME)-accredited medical schools chose to participate in piloting a national curricular resource, the American College of Surgeons/Association of Program Directors in Surgery/Association of Surgical Education Resident Prep Curriculum ("ACS-surgery-prep curriculum"), and implications of such participation for student access nationally to this resource. DESIGN: We examined the significance of school-level differences in ACS-surgery-prep curriculum pilot participation and student-level differences in curriculum access based on medical school attended in bivariate analysis. SETTING: U.S. medical schools choosing to participate in the ACS-surgery-prep curriculum through 2021. Students graduating from U.S. LCME-accredited medical schools in 2020-2021 were invited to complete the Association of American Medical Colleges 2021 Graduation Questionnaire (GQ). PARTICIPANTS: Our study included data for 2569 students intending surgery specialties (16% of 16,353 2021 GQ respondents) from ACS-surgery-prep curriculum pilot and non-pilot schools. RESULTS: Of 148 medical schools attended by 2021 GQ respondents, 93 (63%) were identified as ACS-surgery-prep curriculum pilot schools. Pilot participation varied by school region, community-based designation, and research intensity (each p < 0.05) but not by ownership or transition to residency (TTR) course requirements (each p > 0.05). Of 2569 GQ respondents nationally intending surgery specialties, 1697 (66%) attended an ACS-surgery-prep curriculum pilot school; this proportion did not vary by gender or race/ethnicity (each p > 0.05) but varied by students' school TTR course requirements (p < 0.001). Findings were similar among the 1059 students intending general surgery specialties specifically (41% of all 2569 students intending surgery specialties). CONCLUSIONS: Many U.S. LCME-accredited medical schools piloted this national TTR surgery curriculum. School-level characteristics associated with pilot participation can inform outreach efforts to encourage the participation of interested schools in piloting this TTR resource. With this curriculum distribution model, we observed no gender or racial/ethnic disparities in curriculum access nationally among students intending surgery specialties.

Analysis of adjuvant chemotherapy in patients undergoing curative-intent resection of localized adrenocortical carcinoma.

BACKGROUND: Studies evaluating the role of adjuvant chemotherapy (ACT) in Adrenocortical Carcinoma (ACC) are limited due to its rarity. The objective of this study was to evaluate if ACT provides a survival benefit in patients who underwent curative-intent resection of localized ACC and to determine factors associated with receipt of ACT. METHODS: The National Cancer Data Base was queried to identify patients (2010-2016) with curative-intent resection of localized ACC (T1-T3, N0, M0). RESULTS: Of 577 patients with adrenalectomy, 389 (67%) had adrenalectomy alone, and 188 (33%) received ACT. Private insurance, lymphovascular invasion, stage II, and radiotherapy were predictors of ACT (P < 0.05). Advanced (T3) stage lymphovascular invasion, and being uninsured were associated with decreased OS (P < 0.05). There was no association between ACT and OS. CONCLUSIONS: For patient who underwent curative-intent resection of localized ACC, there was no association between ACT and OS. Private insurance, lymphovascular invasion, stage II disease, and radiotherapy were associated with receipt of ACT.

Impact of general surgery rotation exposure on surgery clerkship performance.

BACKGROUND: Medical students often have variable exposures to general surgery (GS) and subspecialty surgery (SS) during their surgical clerkship. We will evaluate the relationship between clinical exposure to GS and performance on the NBME Subject Examination in Surgery. METHODS: Student data was collected retrospectively from 2015 to 2018 at a single academic institution. Students were categorized based on their clinical clerkship exposure to GS. A linear model was used to estimate the mean difference in NBME performance between GS and strictly SS exposed students while controlling for prior standardized examination scores and completion of an internal medicine clerkship prior to surgery. RESULTS: 365 (67%) of 547 students were exposed to a GS rotation prior to their NBME exam. Performance on the NBME exam was comparable between GS versus SS students (µdiff = 0.37, 95% CI: -0.73 to 1.48; p = .51). CONCLUSIONS: Exposure to a GS rotation is not advantageous on the NBME surgery examination. Students who completed the medicine clerkship prior to surgery demonstrated superior performance on the NBME surgery examination.

Many medical students applying for surgical residency feel inadequately prepared to prescribe post-operative opioids.

BACKGROUND: Little is known regarding medical school curricular variability regarding safe prescribing of post-operative opioids for students entering surgical residency. METHODS: Surveys were administered to general surgery residency interviewees at an accredited academic institution for 2018-2019 application season. Responses were anonymously recorded using web-based software on an electronic tablet. Descriptive statistics were evaluated using proportions and medians with interquartile range. RESULTS: Of 103 eligible, 90 (87.4%) interviewees participated. Although 96.7% of students reported opioid pharmacology during medical school, 35.6% reported their curriculum did not include educational material on acute pain management. While 91.1% felt their curriculum adequately covered opioid related adverse events, 34.4% felt adequately prepared to prescribe post-operative opioids to surgical patients. CONCLUSION: Students entering surgical residency from US medical schools have variable exposures to opioid related educational content and many students feel their medical education inadequately prepared them for prescribing postoperative opioids.

Intraoperative pathologic examination in the era of molecular testing for differentiated thyroid cancer.

BACKGROUND: Diagnostic thyroidectomy is typically indicated for indeterminate thyroid cytology results. Traditionally, intraoperative pathologic examination (IOPE) helped to guide the extent of initial surgery. Preoperative molecular testing (MT) of fine needle aspiration cytology has emerged as another diagnostic adjunct, is highly specific for thyroid cancer, and can lead to appropriate initial total thyroidectomy. We hypothesized that preoperative MT obviates the need for routine IOPE during lobectomy. STUDY DESIGN: In a retrospective, consecutive cohort study, we compared outcomes of 670 patients undergoing thyroidectomy. Cohort A (January 2005 to December 2006) received surgery without MT, and cohort B (January 2008 to September 2010) had preoperative MT for BRAF, RAS, RET/PTC, and PAX8/PPARγ mutations, and cytology assessment by the 2007 modified Bethesda criteria. In both cohorts, IOPE was performed during lobectomy and a positive result prompted total thyroidectomy. RESULTS: In cohort B, total thyroidectomy was more often the initial surgery (62% vs A 45%; p < 0.001) and a positive MT result was the only factor prompting initial total thyroidectomy in 18 (9%) patients. Among 315 patients who had initial lobectomy, thyroid cancer was infrequently diagnosed by IOPE in both cohorts (A 3.6% vs B 1.7%; p = 0.5). The sensitivity of IOPE in detecting differentiated thyroid cancer ≥1 cm decreased >60% with routine use of MT and the Bethesda criteria (A 18.4% vs B 5.9%). After lobectomy, differentiated thyroid cancer ≥1 cm was equally likely to be diagnosed in both cohorts (p = 0.1), but follicular variant papillary thyroid cancer was more common in cohort B (74% vs 45%; p = 0.02). CONCLUSIONS: Together with the Bethesda cytologic criteria, preoperative MT allows for an increased rate of initial definitive total thyroidectomy and eliminates the need for routine intraoperative pathologic examination during diagnostic lobectomy.

Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies.

INTRODUCTION: Molecular testing of fine-needle aspiration (FNA) results helps diagnose thyroid cancer, although the additional cost of this adjunct has not been studied. We hypothesized that FNA molecular testing of two indeterminate categories (follicular lesion of undetermined significance and follicular/Hürthle cell neoplasm) can be cost saving. METHODS: For a hypothetical group of euthyroid patients with a 1-cm or larger solitary thyroid nodule, a decision-tree model was constructed to compare the estimated costs of initial evaluation according to the current American Thyroid Association guidelines, either with molecular testing (MT) or without [standard of care (StC)]. Model endpoints were either benign FNA results or definitive histological diagnosis. RESULTS: Molecular testing added $104 per patient to the overall cost of nodule evaluation (StC $578 vs. MT $682). In this distributed cost model, MT was associated with a decrease in the number of diagnostic lobectomies (9.7% vs. StC 11.6%), whereas initial total thyroidectomy was more frequent (18.2% vs. StC 16.1%). Although MT use added a diagnostic cost of $5031 to each additional indicated total thyroidectomy ($11,383), the cumulative cost was still less than the comparable cost of performing lobectomy ($7684) followed by completion thyroidectomy ($11,954) in the StC pathway, when indicated by histological results. In sensitivity analysis, savings were demonstrated if molecular testing cost was less than $870. CONCLUSIONS: Molecular testing of cytologically indeterminate FNA results is cost saving predominantly because of reduction in two-stage thyroidectomy. Appropriate use of emerging molecular testing techniques may thus help optimize patient care, improve resource use, and avoid unnecessary operation.

Suspicious ultrasound characteristics predict BRAF V600E-positive papillary thyroid carcinoma.

BACKGROUND: Current American Thyroid Association (ATA) guidelines recommend routine cervical ultrasound (US) in thyroid nodule evaluation. Specific US characteristics can help diagnose papillary thyroid carcinoma (PTC). The aim of this blinded cohort study was to determine whether these specific US characteristics can also reliably detect the more aggressive variants of PTC that are often associated with the BRAF(V600E) mutation. METHODS: After Institutional Review Board approval, we identified a cohort of patients from January 2007 to December 2009 with histologic PTC≥1 cm who had cervical US, initial thyroid surgery, and molecular testing for BRAF(V600E) on fine-needle aspiration biopsy or histology. Preoperative US images were evaluated by a single radiologist, who was blinded to BRAF status, for nodule size and the presence or absence of the following suspicious US features: taller-than-wide shape, ill-defined margins, hypoechogenicity, calcifications, noncystic composition, and absent halo. RESULTS: BRAF-positivity was associated with most known suspicious US findings, including taller-than-wide shape (47% vs. 7%, p<0.001), ill-defined margins (42% vs. 9%, p<0.001), hypoechogenicity (83% vs. 36%, p<0.001), micro/macrocalcifications (87% vs. 24%, p<0.001), and absent halo (85% vs. 27%, p<0.001) but was not associated with noncystic composition. When ≥3 suspicious US features were present, BRAF-positivity was predicted with a positive predictive value of 82%. The absence of suspicious US features together with negative BRAF testing predicted PTC without extrathyroidal extension or lymph node metastasis (negative predictive value 88%). CONCLUSIONS: With routine preoperative cervical US and molecular testing, a trained radiologist or surgeon can improve the preoperative characterization of PTC, potentially impacting risk stratification and initial surgical management.